1. Field of the Invention
The invention relates to a doctor performance evaluation tool.
2. Related Art
With the transfer of higher medical costs and premium payroll contributions for health benefits to consumers, payers of medical expenses (including insurance companies and employers who provide insurance benefits to their employees) must now provide more information about the cost of treatment and quality of care associated with such treatment, and other aspects of the medical experience, to patients (consumers, employees and their family dependents). Those payers (herein sometimes called “users”) include the actual consumers of medical care (individuals, their parents or guardians, employees and their dependents) and the insurers of their medical costs (including employers, insurance companies, and government agencies). Many new health benefit plans make employees responsible for “first dollar” healthcare coverage costs (i.e., the employee pays for health expenses out-of-pocket until some benefit limit (deductible) when insurance benefits pay for the cost. These benefit plans can be made more affordable by rewarding consumers who select medical providers that deliver the most cost-effective high quality healthcare. In many cases, patients themselves have significant information about their specific healthcare needs and the types of medical care and providers needed for their treatment. Patients could thus significantly reduce their healthcare coverage costs if only they had adequate information about the specific cost of treatment and quality of care of their potential providers (i.e., doctors, hospitals, other health care professionals) for a specific condition, surgery or procedure.
Currently available information on the cost and quality of services provided by individual doctors is generally minimal at best, aggregated to be of little value, and often merely anecdotal (based on incomplete samples of self-reported, patient satisfaction surveys). Provider directories from insurance companies that help consumers select individual doctors generally exclude any such information on provider cost and quality. If insurance companies publish such performance results in directories on providers, such actual “performance scorecards” are often aggregated at the group practice level and not on the individual doctor level where the patient has a personal relationship. In addition, cost information about patient treatment is often aggregated and does not identify which providers are most cost-effective for surgery or for treating that patient's specific condition. Neither of these approaches provides users with the level of detail necessary to make choices that can minimize cost while maintaining quality, or even select providers based on other criteria important to them, such providers who can treat their condition, providers who have electronic medical records that can check for adverse drug interactions, ease of service or listening skills. Some known individual provider ratings, for example those provided by the NCQA (National Committee on Quality Assurance) provide some guidance to healthcare consumers on treatment of diabetes or heart conditions, but do not provide adequate or detailed enough information for selecting any particular medical provider based on individual provider quality or the user's actual medical condition, or specific treatment need.
Even when users do have access to performance scorecards for individual doctors, known measures of performance relate only to general capabilities of each particular doctor, and do not give useful information regarding capabilities of any particular doctor with regard to a specific healthcare need (such as the patient's medical condition, surgical or procedure need). Although the specialty in which the particular doctor practices, or the particular hospital department in which the doctor practices, might provide very rough information, the information is far too general to allow users to make adequately informed decisions about provider selection, particularly when users have to pay significant out of pocket monies for such health care services.
This problem is particularly acute when the user is looking for doctors that can best treat the user's particular medical condition, particular surgical need, particular medical history, or user's particular demographic profile. For example, an overweight male patient in his 50's with a family medical history of coronary disease might seek out a provider with best capabilities at coronary heart disease and its related medical conditions, while a newly married female patient in her 20's might seek out a provider with best capabilities at pregnancy and family issues. The latter might even specifically wish to have a female doctor. A user who already has a specific known medical condition, whether very specialized (say, allergy), or not (say, diabetes), or having both non-physical and physical components (say, psychopharmacology), will almost certainly wish to select a medical provider with best capabilities in that known medical condition and similar medical conditions. In known systems and provider directories, information about providers is limited to each medical provider's certifications, credentials, malpractice history, service locations, or general practice areas. While this does give the user some information about the general class of medical conditions that medical provider is capable of treating, it has the drawback of failing to provide specific information regarding the medical provider's actual record of prevention and treatment of the user's specific medical problems (whether current or anticipated).
Even where there is an attempt to measure individual doctor performance, current models do not adequately serve the user in providing unbiased and statistically valid measures. Disregarding their possible bias and statistical invalidity, the measures that do exist are not representative of the particular medical conditions and patient population diagnosed and treated by those medical providers. Current performance measures generally focus on a few aspects of the medical provider's practice, but do not reveal enough information to adequately judge the entire range or scope of the medical provider's practice across different patient panels and patient treatments, including relatively healthy patients, occasionally sick patients, and chronically ill patients. This has the effect that measured performance for distinct medical providers could vary substantially in response to their differing patient populations, rather than in response to an individual user's needs.
For example, one known method, a “patient weighted” measurement, is responsive, for each medical provider, to an average score of their performance across a set of intervention opportunities. Each performance measure represents a component of that total average score. The total average score is weighted by the volume of intervention opportunities. This method has the substantial drawback since each medical provider's score is most heavily weighted toward the component of that average in which they treated the largest number of patients. Those measures with a smaller volume of intervention opportunities which are equally important as high volume intervention opportunities do not receive equal weight. This drawback is substantial and creates biased results because, among other reasons, certain measures of quality may apply to patients with a first type of condition (e.g., preventative care of the heart—cholesterol screenings) where the patient sample size per doctor is very large, but are substantially valuable in measuring the same doctor for a second type of condition (e.g., patients with coronary artery disease) where the patient sample size is small.